Case

Left Main Ostial and Shaft Lesion Treated with Cross-Over Technique Using Single Sirolimus-Eluting Stent

- Operator : Alan C. Yeung

Left Main Ostial and Shaft Lesion Treated with Cross-Over Technique Using Single Sirolimus-Eluting Stent

- Operator: Alan C. Yeung, MD, Teguh Santoso, MD,

Clinical Presentation

A 35-year old woman was admitted due to effort chest pain for 1 month. She had no risk factors. Baseline ECG showed T wave inversion in V3-6 and left ventricular systolic function was normal.

Baseline Coronary Angiogram

1. Left coronary angiogram showed a significant left main coronary artery (LMCA) ostium and shaft narrowing (Figure 1, Figure 2).
2. Right coronary angiogram was normal.

Procedure

A 7F sheath was inserted through right femoral artery, and the left coronary ostium was engaged with a 7F JL catheter with 3.5 cm curve. Two 0.014 inch BMW wires were inserted into the left anterior descending artery (LAD) and left circumflex artery (LCX), respectively (Figure 3, Figure 4). Intravascular ultrasound (IVUS) examination showed severe atheromatous plaque burden from ostium to shaft of LMCA without negative remodeling (Figure 5) and mild plaque burden at the ostial LCX (Figure 6). Therefore, a 3.5 X 13 mm Cypher stent was positioned at the LMCA ostium extending to the LAD ostium and deployed by 14 atm (3.67 mm), crossing the LCX (Figure 7). Post-stent IVUS revealed good results without malapposition of the stent (Figure 8). Final angiogram showed a well-expanded stents without residual narrowing (Figure 9, Figure 10, Figure 11).
||

Comments

  • Roberto Baglini 2006-08-18 I am sorry but in my opinion to put a drug eluting stent on the left main is not an acceptable way to solve the problem of myocardial revascularization in these patients. Unfortunately DES are not the ultimate solution as they has the intrinsec tendency to jeopardize the coronary endothelium putting the patient at risk of subacute or late stent thrombosis. In this kind of patients stent thrombosis will necessarily result in death. Evidence are arising that the long term mortality rate in DES treated patients is possibly superior to the surgical one. No clear recommendation exists up to now to treat left main coronary artery disease with drug eluting stents.
  • M Kurdi 2006-08-18 i think concerdering the young age of the patient and in the current era where there is not a clear right and wrong answer for such a problem and with the arising evidence of the safety of LM stenting ,it is acceptable to treat such a problem through the PCI but need close follow up and repeated angiography in 6 months with IVUS to assess the LCX as well.
  • Dobrin Vassilev 2006-08-19 Pretty good result. What about ostium of LCx? On your fig9 it seems that thereis a significant stenosis? You do not performed final kissing? Flaring of ostium of a stent?
  • Raghu C 2006-08-21 I think it is mandatory to perform a final kissing ballloon inflation to have access to tyhe LCX at a later date and also to have a better MACE.
  • mohsen Dehgani MD 2006-08-21 good result.i thing for to use DES in Laft Maine need more time and more study
  • Jae Sik Jang 2006-08-26 Final kissing balloon at LCX may provide better result in case of some stenosis in LCX. But in this case, because there was non-significant plague burden, it is not mandatory to perform final kissing. We routinely conduct a 6 month angiographic follow-up and even earlier if clinically indicated by symptoms or documentation of myocardial ischemia. We performed more than five-hundred unprotected left main stenting and showed good result. PCI with DES may be a good alternative to CABG for a patients with relatively young age with preserved LV funciton
  • ANAZI 2006-08-27 one would've thought that a nice LIMA and Radial are more safe in a 39 year old with a left main but I could be wrong ( I hope I am wrong )!
  • christopher wong 2006-09-04 The IVUS examination demonstrated the media to media of the LMCA was larger than 4.0mm. Was there a consideration to post dilate the stented region with a 4.0 mm noncompliant balloon?
  • vijaykumarpuri 2006-09-30 1flaring of lcx ostia .why not bms why not 4mm stent in lmca position
  • Fadili 2009-04-28 Good flow in LAD, not very clear LCx. Why did you decide to put a DES in LM? How long did you recommend the patient to take Clopidogrel? Lifelong?

Leave a comment

Sign in to leave a comment.